The Effects of Familiar, Unfamiliar Music and Audiobooks Exposure on Speech Parameters of Elderly Withalzheimer’s Disease a Within Case Stud

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Deskripsi:

Alzheimer’s disease is a cognitive disorder common among elderly whereby neurode generation occurs rapidly as a result of decline in brain activity. There have been many studies linking music memory with cognition among patients with Alzheimer’s disease. However, the types of music exposed, the familiarity of the music and their effects on speech production is still not adequately explained. Improvement in speech can be demonstrated in alteration of several speech parameters. This multiple case study (n = 3), seeks to investigate the effects of familiar and unfamiliar music on the speech fundamental frequency (F0), intensity range, and speech rate of 3 elderly subjects with Alzheimer’s disease. The speech parameters after exposure to familiar and unfamiliar music were measured longitudinally over a period of 21 weeks. A listening task to an audiobook was treated as control. Data revealed that in all of these subjects, there was wide variability in performance with no common pattern for familiar music. However, for unfamiliar music, two subjects showed increase in their speech rate. The third subject showed increase in F0 range. It is suggested that there may be more to understand how familiar and novel stimuli influence speech production in patients with Alzheimer’s disease.
Keywords
Alzheimer’s Disease (AD), Familiar, Unfamiliar, music, Speech production

The Effects of Familiar, Unfamiliar Music and Audiobooks Exposure on Speech Parameters of Elderly Withalzheimer’s Disease a Within Case Stud

Diunggah oleh

Deskripsi:

Alzheimer’s disease is a cognitive disorder common among elderly whereby neurode generation occurs rapidly as a result of decline in brain activity. There have been many studies linking music memory with cognition among patients with Alzheimer’s disease. However, the types of music exposed, the familiarity of the music and their effects on speech production is still not adequately explained. Improvement in speech can be demonstrated in alteration of several speech parameters. This multiple case study (n = 3), seeks to investigate the effects of familiar and unfamiliar music on the speech fundamental frequency (F0), intensity range, and speech rate of 3 elderly subjects with Alzheimer’s disease. The speech parameters after exposure to familiar and unfamiliar music were measured longitudinally over a period of 21 weeks. A listening task to an audiobook was treated as control. Data revealed that in all of these subjects, there was wide variability in performance with no common pattern for familiar music. However, for unfamiliar music, two subjects showed increase in their speech rate. The third subject showed increase in F0 range. It is suggested that there may be more to understand how familiar and novel stimuli influence speech production in patients with Alzheimer’s disease.
Keywords
Alzheimer’s Disease (AD), Familiar, Unfamiliar, music, Speech production

AbstractAlzheimers disease is a cognitive disorder common among elderly whereby neurodegeneration occurs rapidly as a result of decline in brain activity. There have been manystudies linking music memory with cognition among patients with Alzheimers disease.However, the types of music exposed, the familiarity of the music and their effects on speechproduction is still not adequately explained. Improvement in speech can be demonstrated inalteration of several speech parameters. This multiple case study (n = 3), seeks to investigatethe effects of familiar and unfamiliar music on the speech fundamental frequency (F0),intensity range, and speech rate of 3 elderly subjects with Alzheimers disease. The speechparameters after exposure to familiar and unfamiliar music were measured longitudinallyover a period of 21 weeks. A listening task to an audiobook was treated as control. Datarevealed that in all of these subjects, there was wide variability in performance with no397 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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common pattern for familiar music. However, for unfamiliar music, two subjects showedincrease in their speech rate. The third subject showed increase in F0 range. It is suggestedthat there may be more to understand how familiar and novel stimuli influence speechproduction in patients with Alzheimers disease.KeywordsAlzheimers Disease (AD), Familiar, Unfamiliar, music, Speech production

1. Introduction1.1 Alzheimers DiseaseIn Malaysia, 7 out of 100 elderly people experience dementia (Nikmat, Hawthorne,Al-Mashoor, 2011). Elderly people are defined as people above the age of 60 (Minhat,Rahmah, Khadijah, 2013, Minhat, Amin, Shamsuddin, 2012, 2014). A contributing factor todementia is a reduction in brain activity due to the lack of engagement in cognitivedemanding activities, especially after retirement (Wan, Ruuber, Hohmann, Schlaug, 2010).Alzheimers disease (AD) is the most common type of dementia affecting 60 to 80% ofdementia cases in the United States (Alzheimers Association, 2015, p.6) which occursduring aging. AD is a neurocognitive disorder, whereby neurodegeneration occurs rapidly inthe brain, particularly causing memory loss in patients (Alzheimers Association, 2014).In the Malaysian context, the elderly in Malaysia generally show less involvement incognitive and physical activities, instead indulging more in social or passive sedentaryactivities (Minhat, Rahmah, Khadijah, 2013, Minhat, Amin, Shamsuddin, 2012, 2014). Basedon previous findings, the Malaysian elderly tend to gravitate towards sedentary lifestyles suchas watching television (74.6%), social activities such as having conversations while relaxing(78.7%), and show poor involvement in constructive and stimulating activities such asplaying cards, chess or mah-jong (3.4%), playing musical instruments (1.1%), writing ordrawing for pleasure or involvement in formal teaching (Minhat, Rahmah, Khadijah, 2013,Minhat, Amin, 2011). High engagement in passive and sedentary lifestyles could eventuallylead to a decline in brain activity among the elderly, putting them at higher risk to suffer from398 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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chronic illnesses, mental deterioration and cognitive disorders such as Alzheimers disease(Minhat, Amin, 2011, Wan, Ruuber, Hohmann, Schlaug, 2010, Hall and others, 2009).Memory, attention, experience, communication skills and learning are all interlinkedas they are influenced by activation of the auditory system (Kraus et al., 2014). There is alsoan overlap between music and language processing centres in the brain (phonological andtonal loop in the working memory). This is why the hallmark symptoms of AD includememory loss (Alzheimers Association, 2014) and deficit in the working memory.As mentioned earlier, Alzheimers disease is a neurodegenerative disease, progressingwith time (Haneishi, 2001, Alzheimers Association, 2014). In other words, the cognitiveskills of an individual with AD will worsen or deteriorate over time. In relation to this,impairment in the working memory from the early stages of the disease, will affect learning,attention span (Lake and Goldstein, 2011, Bourgeois and Hickey, 2009, Cayton, Graham,Warner, 2008), and language (Roark et al., 2011, Bourgeois and Hickey, 2009, Cayton et al.,2008) in these individuals.1.2 Breakdown in CommunicationLanguage is used during communication as a process of transmission of information(Littlejohn and Foss, 2010). Language in communication plays an important role as it givesus the ability to speak, allowing us to participate in life (Stotsky, 1992 in Morreale, Osbornand Pearson, 2000, Cayton et al., 2008, Stiadle, 2014). As such, debilitation incommunication may lead to frustration in patients and their family members, causing them towithdraw from conversation and social activities (Ramig, 1995 in Haneishi, 2001). This inreturn would seriously impair their quality of life (Haneishi, 2001).

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Figure 1: Difficulties in Communication at Different Stages of Alzheimer s disease

Difficulty in communication can be observed in individuals with AD; this is due tothem demonstrating a lack of semantic skills and suffering word-finding difficulties duringthe early stages of the disease (Cayton et al., 2008, Bourgeois and Hickey, 2009, Stiadle,2014). Despite retaining their ability to participate in social conversations, these individualsmay struggle to comprehend complex syntax in speech (Stiadle, 2014). Their conditionworsens as they enter the middle-stages of the disease, whereby they begin to exhibit namingdeficits and increased production of empty speech (Cayton et al., 2008, Bourgeois andHickey, 2009, Stiadle, 2014). During this stage, individuals experience difficulty maintaininga topic of conversation which leads to repetitive verbalization. Once they move into thesevere stages, they experience severe impairment in language, making it extremely difficultfor spoken language to be interpreted (Cayton et al., 2008, Lubinski, 1995 in Stiadle, 2014).At this stage, their extreme language impairments and inability to express their needs orwants (Bourgeois and Hickey, 2009), hinders participation in social interactions (Lubinski,1995 in Stiadle, 2014). They eventually also lose their ability to care for themselves, thusrequiring the assistance of a caregiver.1.3 Music as a TherapySince it has been stated that language impairment in AD patients are a result of failurein the working memory (Bourgeois and Hickey, 2009), several researchers have tested the400 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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usage of musical encoding on the stimulation on memory (Simmons-sterns, Budson, and Ally,2010, Simmons-stern et al., 2012). Their studies revealed that musical encoding can facilitatefamiliarity as well as enhance attention. This is because familiarity for musical stimuliactivates medial temporal lobe brain regions (Plailly, Tillmann and Royet, 2007, Simmonssterns et al., 2012).This is supported by other studies showing that musical activities such as passivelistening have been proven effective in stimulating the insulae (Bamiou, Musiek, Luxon,2003) which is vital in speech processing and production (Straum and Brotons, 2000). Basedon the earlier Baddeley and Hitchs model (1986, 2000, 2003), the working memory (whichis affected during Alzheimers disease) was shown to be comprised of only the phonologicalloop which processes both music as well as speech. In contrast, recent studies have proventhat music and speech have anatomical overlap (Patel, 2014) but are still processed in thephonological loop and tonal loop (Schulze et al., 2010).Previous researches showed the effectiveness of familiar music in stimulatingrecollection (Basso, Basso and Belardinelli, 2004 in Platz, Kopiez, Hasselhorn, Wolf, 2015)and enhancing memory in Alzheimers patients. The effect of unfamiliar music onAlzheimers disease patients, however, has not yet been fully explored. Pereiras study (2011)postulated that unfamiliar music yielded several active regions in the left hemisphere,specifically the insula, which is vital in speech production.1.4 AimsRecently, studies have shown that non-invasive methods such as the measuring of speechparameters can be used in assessing the impact of neurodegenerative impairments of speechand language. This is seen via speech parameters measured in spoken language (Roark et al.,2011) and spontaneous speech (Singh, Bucks and Cuerden, 2001) which can be used asmarkers in determining the level of severity in demented patients.Therefore, the principal objectives of the study are as follows.

To investigate the effect of music therapy on the improvement speech production in

subjects with AD based on the measurements of the rate of speech, overallfundamental frequency, and speech intelligibility.401

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To observe the changes before (pre-treatment) and after (post-treatment) exposure to

the type of stimuli on the speech production of the elderly subjects with AD.

Based on these objectives, this research serves to study the difference in the effect offamiliar and unfamiliar music on the verbal memory of elderly patients with Alzheimersdisease.

2.0 Methodology2.1 SubjectsThree Chinese females with diagnosis of AD and affiliated with the Alzheimersdisease Foundation Malaysia, ranging from the ages of 70 to 85 years were selected toparticipate in this study. Selection criteria included individuals who (a) aged 60 years andabove; (b) had Alzheimers disease diagnosed by a neurologist or psychologist withimpairment predominantly in memory; (c) had scores of 21 and below in the MMSE andMOCA test.Subjects were excluded if they (a) demonstrated aggressive behaviours; (b) had severedepression which is determined from their medical records; (c) had other types of dementia(example: Lewy body, Parkinsons disease; (d) had history of traumatic brain injury orneurological diseases; (e) were bedridden, and have significant chronic disease; (f) wereunder drugs such as psycho(drugs); (g) showed severe depression; (h) showed aversion tomusic; (i) were in their final stages of Alzheimers disease; (j) had hearing impairment.2.2 Pre-experimentBefore beginning the experiment, two neuropsychological tests were carried out togauge the mental status of the subjects, namely, the Mini-Mental Status Examination(MMSE), and The Montreal Cognitive Assessment test (MoCA), (Razali et al., 2012). TheMMSE test required subjects to perform tasks for cognitive domains, including orientation oftime and place, short and long term memory, registration, recall, constructional ability,language and the ability to understand and follow commands. The Montreal CognitiveAssessment (MoCA) involved assessments of various cognitive domains: attention andconcentration, executive functions, memory, language, visuo-constructional skills, conceptual402 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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thinking, calculations, and orientation (Quinn, 2013). For better accuracy, average of totalscores from both the MMSE and MoCA test were calculated to determine the mental state ofthe patients (Moretti, Frisoni, Binetti, Zanetti, 2012, Razali et al., 2012). Table 1 indicates theclassification of category based on average of MMSE and MoCA scores:Table 1: Classification of stages of AD based on average of MMSE and MoCA scoresScores25-3021-2410-210-9

CategoryNormalMild ADModerate ADSevere

Baseline measurements for language were taken from the scores for language and theworking memory segments found in the MMSE and MoCA tests.Apart from the neuropsychological testing, the Assessment of Personal MusicPreference (APMP) by Gerdner (2000) (see Appendix 1), was carried out. In the APMPsurvey, subjects and caregivers were required to fill in the subjects favourite types of music,favourite artists, and genre or song titles. Based on results from the APMP survey,individualized music playlists were designed for the participants, respectively. Songs in theindividualized music playlist were used when subject is exposed to familiar music stimuli. Inthis study, familiar music refers to music which have been previously heard by the subjects(Plailly, Tillman, Royet, 2007) or was often listened to by the subjects. If there is noinformation filled in the APMP form, the list of songs played during sing-along sessions inthe ADFM day care center will be used as familiar music.Subjects receiving unfamiliar music stimuli on the other hand, were given music thatwas not stated in their survey. The unfamiliar music selected were music which the subjectsthat they have no knowledge of, or have not previously heard. Both familiar and unfamiliarmusic consisted of vocals, comprising of the same genre of music with similar tempo andrhythm in order to minimize deviation in results (Plailly, Tillman, Royet, 2007, Jungers,Speer, Palmer, 2002). During the experiment, music was played from the media player in arandomized order. A report on the list of songs used for the week was recorded for analysispurposes.403 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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During the control phase, subjects were any music stimuli during therapy sessions.Instead of music, they were exposed to audiobooks based on their spoken language, whichwill be played via the media player. Audiobooks were selected as a control as it is a proxy tovocal music.2.2 ProcedureEach subject had to undergo an individual, 20-30 minute, twice a week session, forseven weeks (Lin et al., 2011, Sung et al., 2012, Craig, 2014). During the sessions, thesubjects were given either familiar, unfamiliar or audiobooks (control phase). After eachphase (14 sessions, 7 weeks), a crossover was done to observe the different effects of stimulion each subject. This means that each subject went through a total of 42 sessions, with awash-over period of two weeks in between each phase (14 sessions). The arrangement ofsequence of stimuli differed for each subject to observe if it would have an effect on thecollected data (Table 2).Table 2: Arrangement of stimuli for each subjectSubjectABC

Sequence of StimuliF1 x UF x CUF2 x C x FUF x F x C3

This study is a multiple within subject case study. This method was selected becausepatients with Alzheimers disease may present similar symptoms, but, exhibit differentpatterns of behaviour problems (Bourgeois and Hickey, 2009, p.63). Hence, a within multiplecase study method enables us to gain better understanding regarding the effect of the threedifferent types of stimuli on each subject respectively over time (Baxter and Jack, 2008).During the session, each subject was given a pair of headphones with music playlist inthe media player. Headphones were used instead of free-field as the background noise mayaffect the task performance of the participants. By using headphones, background noiseswould be filtered out, lowering anxiety among subjects during task performances (Hygge,1

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Evans, Bullinger, 2002). While music exposure usually lasted around 25-30 minutes, thesubjects were given a relatively shorter period of exposure (10 minutes) to stimuli as subjectswith AD have shorter attention span (Lake and Goldstein, 2011).

Figure 2: Virtual image of experiment set-up

After listening to individualized music for about 10 minutes, the music was stopped.Open-ended questions were used to attain a wide range of responses, and encourage higherverbal rate from subjects (Singh et al., 2001). Subjects responses were recorded using audiorecorders. All audio recordings were carried out pre-exposure and post-exposure to musicstimuli during every session, throughout the whole duration of the research. Audacity wasused to measure the speech rate of the participants. The Phonetogram was used to measurethe speech intensity (SPL range), the fundamental frequency (F0 range) and area of speech.For fundamental frequency, the maxima and minima of F0 were determined in order to obtainthe F0 range. Pitch intervals of speech were also calculated whereby the highest F0 value ofthe recording was divided by the lowest F0 value (Jones and Knight, 2013). In other words, F0range referred to the contour track or pitch track of the speech. The speech rate wascalculated based on the number of words uttered per minute (Watt as cited in Jones and405 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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Knight, 2013, p. 83). Area of speech showed the relationship between the speech intensity(SPL range) and (F0 range). Speech intensity on the other hand, indicated the amplitude orloudness of speech (Jones and Knight, 2013)The topics of discussion and observations of mood responses from the subjects duringeach session are recorded in a journal.

3. Results and Discussion

In order to gauge improvement during each session, the difference between the preexposure and post-exposure for all speech parameters (speech rate, F0 range, SPL range andarea of speech) are calculated. The formulae below shows the way the data was used indetermining improvement in various speech parameters.i)

Calculation during each session:

ii)

Calculation of average for each phase:

Based on equation (i), a positive value indicated improvement during the post-

exposure of that particular session. The difference from each session totalled-up at the end ofeach phase (14 sessions) and divided by 14 to attain the total average of mean difference(equation ii), which is calculated using the SPSS program. T-test was used to determineimprovement of speech parameters before and after exposure to specific stimuli. All resultsattained were based on comparison within subjects.Table 3 contains the means (standard deviation) for speech rate, fundamentalfrequency ranges, area of speech and speech intensity pre and post-session, for each stimulusaccording to respective subject.Table 3: Means and standard deviations of speech parametersSubject AParameter

Generally, there was no recognizable pattern attained from the pre-exposure and postexposure to both familiar and unfamiliar music across all three subjects, whereby each ofthem exhibited variable performances in speech measures.All three subjects did however, show significant positive responses towardsunfamiliar music. Both subjects, subject B and C (moderate AD), showed improvement inspeech rate, p < 0.001. This indicates that exposure to unfamiliar music increased their

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music

music

Occasionally fallsasleep

Results showed that subjects exhibited improvement when exposed to unfamiliar

music. However, these results did not necessary indicate their level of preference orenjoyment towards the type of music listened to.Observations when the stimuli were given to the subjects and feedbacks of theirenjoyment were recorded at the end of each session showed a sense of enjoyment towardsmusic stimuli (both familiar and unfamiliar) over audiobooks. This was perceived viahappiness in their facial expression which was also seen in a study by (Bouhuys et. al., 1995in Juslin and Vastfjall, 2008). However, their responses towards the type of music given weredifferent. When exposed to familiar music, subjects would either hum or sing along to thesongs played. On the other hand, when subjects showed responses during exposure tounfamiliar music, they would either tap their fingers on the table or tap the tip of their footslightly.Exposure to audiobooks however, resulted in a different form of response; whenexposed to audiobooks, subject B and C would occasionally fall asleep, which was almostnever observed when exposed to music stimuli. Subject C showed a neutral response towardsthe audiobooks, whereby she would just listen to the stimuli quietly. Subject A (severe AD)did not respond well when given audiobooks, as she would continually mutter to herselfwhile looking down, having a disturbed expression. During the post-exposure to audiobooks,subject A expressed feelings of discomfort as she felt that the narration in the audiobookswere directed at her. Subject B (moderate AD) showed slight aversion towards theaudiobooks, as there were times when she would form excuses in order to decline herparticipation in that particular session. Once we reverted back to music in the last phase, shedid not exhibit any more difficulty in participating in the sessions. This was also seen in aprevious study (Wood et al., 1990 in Juslin and Vastfjall, 2008), whereby music increased thewillingness of one to participate in social activities.For all sessions, the topics of conversation during pre-exposure and post-exposurewere mostly of the same content for each subject respectively throughout the whole study. In409 2016 The author and GRDS Publishing. All rights reserved.Available Online at: http://grdspublishing.org/

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general, the topics of discussion were mostly centered on their families, their childhood,romantic life, personal interests, and current everyday life. These topics seemed to interest thesubjects, allowing them to be more engaged in the conversation. They showed the mostamount of engagement when discussing about their loved ones. However, the subjectsmoods during each session did affect the engagement in the conversations. When subjectsexperienced mood swings, they tend to withdraw themselves from engagement inconversations, which was frequently observed in subject B. This may be an indication of theassociation between language, mood and behavior (Potkins et al., 2003 in Bourgeois andHickey, 2009, p. 64)When exposed to familiar music (especially romantic songs, for example Love MeTender by Elvis Presley or Cant Help Falling in Love with you by Nat King Cole), subjectstended to discuss more about their love life when they were young. Exposure to familiarmusic tend to sway the conversations more into topics of their past, such as their childhood(Stevens, 2015). A study (Davidson and Garrido, 2014 in Stevens, 2015) mentions that musicis able to trigger nostalgia, being a catalyst for remembering particular events, people,emotions and places. When exposed to unfamiliar music, we were able to tap into questionsregarding their personal interests as well as their current everyday life. However, most of thetime, the topics of conversation would eventually revert back to family topics.The mood of the subjects seems to affect the measures of speech; SPL range, F0ranges and speech rate of the subject. This is supported by previous studies (Gobl andChasaide, 2003, Ellgring and Scherer, 1996), stating the way different moods and emotionsaffect the changes in voice quality. When subjects were excited (for example, angry orhappy), they tend to exhibit larger area of speech, higher F0 ranges, SPL range and speechrate. When the subject showed fear or discomfort (which were observed in subject A and B),they tend to exhibit smaller area of speech, lower F0 ranges, SPL range and speech rate(Markel, Bain and Phillis, 1973 in Ellgring and Scherer, 1996).The results show more significance on a session to session level, rather than theaccumulative sessions in the phase as a whole. This may indicate that there is no long-term

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effect of the stimuli on the speech production of the subjects. However, difference in effect ofstimuli can be weighed from pre to post session.

5. ConclusionAll three subjects showed variable performances without specific or well definedtrend in the speech measures and agreed with previous studies (Cohen and Masse, 1993 inHaneishi, 2001) which stated that patients with neurodegenerative disease cannot beinterpreted similarly those with non-degenerative disease. The results also suggest thatunfamiliar music may have significant effect on the speech rate of subjects with AD, however,it is difficult to gauge the long term effect of music on speech production of theseAlzheimers disease patients. Instead, the results indicated that there may be more tounderstand how familiar and novel stimuli influence speech production in Alzheimersdisease patients.Future studies should include active music therapy with video recordings of facialexpressions and a scale to measure the improvement of quality of life (QOL).